The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin,

under the Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

www.lsqin.org | Follow us on social media @LakeSuperiorQIN

QAPI Written Plan How-To Guide

Created by Lake Superior Quality Innovation Network

For Participants In the National Nursing Home Quality Care Collaborative

August 2016

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

Table of Contents QAPI Written Plan: Introduction .............................................................................................................. 1

Purpose of Your Organization’s QAPI Plan ............................................................................................. 1

Scope ......................................................................................................................................................... 3

Resources .............................................................................................................................................. 4

Guidelines for Governance and Leadership ............................................................................................. 5

Resources .............................................................................................................................................. 7

Feedback, Data Systems, and Monitoring ................................................................................................ 8

Example: Data Sources to Analyze Performance ............................................................................. 9

Example: Data Sources to Identify Risk ......................................................................................... 11

Example: Data Sources to Collect Feedback/Input ........................................................................ 13

Performance Improvement Projects (PIPs) ............................................................................................ 14

Resources ............................................................................................................................................ 17

Systematic Analysis and Systemic Action ............................................................................................. 19

Resources ............................................................................................................................................ 20

Appendix: Template, Sections, and Blank Tables .................................................................................. 21

About Lake Superior Quality Innovation Network ................................................................................ 25

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Introduction and Purpose – Page 1

QAPI Written Plan: Introduction Quality Assurance and Performance Improvement (QAPI) is a data driven and proactive approach to quality improvement. All members of an organization are involved in continuously identifying opportunities for improvement. Gaps in systems are addressed through planned interventions with a goal of improving the overall quality of life and quality of care and services delivered to nursing home residents. The QAPI plan will guide your organization’s performance improvement efforts. The regulation surrounding QAPI includes a written plan. This plan is a framework for an effective, comprehensive, data driven program that focuses on the indicators that reflect outcomes of care and quality of life. The plan will assist your organization in achieving what you have identified as the purpose of QAPI in your organization. The QAPI plan is also intended to be a living document that your organization will continue to review and revise. Your written QAPI plan will be made available to a state agency, federal surveyor, or CMS upon request. It reflects the way your organization has developed, implemented, and maintained your quality program. To write your organization’s QAPI plan, use the numbered sections, highlighted in gold. These sections are what is currently included in the proposed regulation and previously published in CMS’s QAPI tools and resources. Under each section, there is a description of what your organization should include in the section, followed by an example. You can begin with this language, but should include language that best describes the unique characteristics of your organization. An Appendix is provided you for to write your QAPI plan. This Word format document is intended to allow you to write, copy, paste, edit, etc. When completed, you will have your written QAPI plan.

Purpose of Your Organization’s QAPI Plan The first section will describe the purpose of your QAPI plan. Before writing this section, locate your organization’s mission statement, vision statement, and/or guiding values:

A. A vision statement describes what your organization strives to do and is sometimes referred to as a picture of your organization in the future. The vision statement is what your organization aspires to and is the framework for strategic planning.

B. A mission statement describes the purpose of your organization. It guides the decision-making and defines overall goals and actions. The mission statement provides a framework or context for the organization’s strategies.

C. Guiding values or principles are defined actions that all staff will perform. It’s a guidance for everyone in the organization and frames the culture in the organization.

1. Write the Purpose of Your Organization’s QAPI Plan

Include language that is specific from your vision statement, mission statement, and/or guiding principles. This language is specific to your organization. Describe how the QAPI plan is consistent with and framed on the principles that guide your organization. Provide as much description as possible to show the connectedness between your vision, mission, guiding principles, and the quality improvement culture within your organization. Describe the goals the QAPI plan will strive to meet.

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Introduction and Purpose – Page 2

Describe how your organization works to continuously improve the areas that are of great importance. Describe how often this plan will be reviewed, who will be reviewing it, who will receive communication about any revisions to the plan, and the method of communication.

Example Our organization’s written QAPI plan provides guidance for our overall quality improvement program. Quality assurance performance improvement principles will drive the decision making within our organization. Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care, and resident transitions. Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in our organization. The administrator will assure that the QAPI plan is reviewed minimally on an annual basis by the QAPI committee. Revisions will be made to the plan ongoing, as the need arises, to reflect current practices within our organization. These revisions will be made by the QAPI committee. Revisions to the QAPI plan will be communicated as they occur to board members, residents, families, and staff through meetings and newsletters.

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Scope – 3

Scope This section describes the scope of how QAPI is integrated across and into the full range of care and service areas of your organization. Each of these services areas will be involved in the organization’s overall QAPI plan and involved in QAPI activities. 2. List of Services You Provide to Residents

List all services your organization provides for residents. These service areas will be included in the QAPI plan and involved in QAPI activities. Each organization is unique and has its own complexity. Describe the full range of care and services. Areas that might be included are: dementia care, hospice, long term care, memory care, post-acute care, rehabilitation services, etc.

Example QAPI activities will be integrated across all the care and service areas of our organization. Each area will have a representative on the QAPI committee. Our service areas will work together whenever possible to integrate care and services across our continuum of care to better meet the needs of the residents living in our community. Our QAPI activities will cross service areas and departments and we will work together to assure we address all concerns and strive to continuously improve the provided services. Our service areas include: • Dementia Care • Hospice • Long Term Care • Palliative Care • Post-Acute Care • Rehabilitation services • Transitional Care

3. Describe How Your QAPI Plan Will Address Key Issues Describe how your QAPI plan will address:

• Clinical care • Individualized goals and approaches for care • Quality of life • Resident choice • Safety and high quality clinical interventions while emphasizing autonomy and choice for

residents and their families

Example Our organization provides services across the continuum of care. These areas have an impact on the clinical care and quality of life for residents living in our community. All departments and services will be involved in QAPI activities and the organization’s efforts to continuously improve services. The principles of QAPI will be taught to all staff, volunteers, and board members on an ongoing basis. QAPI activities will aim for the highest levels of safety, excellence in clinical interventions, and resident and family

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Scope – 4

satisfaction. All organizational decisions involving residents will be focused on their autonomy, individualized choices, and preferences, and to minimize unplanned transitions of care. The organization will partner with each resident, their family, and/or advocate to achieve their individualized goals and provide care that respects their autonomy, preferences and choices. When the need is identified, we will implement PIPs to improve processes, systems, outcomes, and satisfaction.

4. Current Quality Assurance Activities

Describe how QAPI will integrate and expand current quality assurance activities. The review of data must continue to assure that systems are being monitored and processes are maintained to achieve the highest level of quality for your organization. Data should be reviewed against benchmarks, such as national, state, corporate, or organizational targets. In addition, data must be monitored to identify new areas for improvement. This monitoring and review of data and systems will begin the identification of quality improvement projects.

Example The QAPI committee will review data from areas the organization believes it needs to monitor on a monthly basis to assure systems are being monitored and maintained to achieve the highest level of quality for our organization.

5. Use of Best Available Evidence

Describe how your organization will utilize the best available evidence (e.g., data, corporate, regional, state and national benchmarks, recognized best practices, clinical guidelines, etc.) to compare your organization against, establish goals for improvement, and define measurements to show improvement.

Resources

• QAPI 5 Elements: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/qapifiveelements.pdf

• QAPI At a Glance: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIAtaGlance.pdf

• QAPI Self-Assessment Tool: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPISelfAssessment.pdf

• Guide for Developing Purpose, Guiding Principles, and Scope for QAPI: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIPurpose.pdf

• Guide for Developing a QAPI Plan: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIPlan.pdf

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Governance and Leadership – 5

Guidelines for Governance and Leadership 6. Responsibility and Accountability

Describe how QAPI is integrated into the responsibilities and accountabilities of top-level management. Who will have responsibility and accountability to assure QAPI is implemented in the organization? Is it the administrator, CEO, director of nursing, board of directors, etc.?

Example The administrator has responsibility and is accountable to the board of directors/corporation for ensuring that QAPI is implemented throughout our organization.

7. Describe how QAPI will be adequately sourced

QAPI activities need leadership support as well as financial resources to ensure the activities can occur. PIPs need staff meeting time, as well as time to implement the strategies they develop. Often, nursing assistants, nurses, and others involved in direct care activities need to be replaced for meetings so that resident care does not suffer. Sometimes performance improvement projects require environmental changes or staffing changes. This takes planning and responsiveness from leadership who control budgets. Describe the process for addressing these issues.

Example The administrator and financial officer will establish a budget to ensure that QAPI activities are supported. These expenses may include, but are not limited to staff time for being involved in Performance Improvement Projects and meetings, monies needed for improvement projects, staff training and education, etc. This budget will be reviewed on a monthly basis by the administrator and revised as necessary. The administrator and QAPI committee will work together to review budgetary needs and share decision making regarding performance improvement projects.

8. Determine the plan for mandatory QAPI staff training and orientation Describe how your organization will ensure that all staff receive training on QAPI principles and how your organization implements QAPI. Staff responsibilities on how to bring forward opportunities for improvement and participation on PIP teams and the QAPI committee should be discussed. This education is mandatory for all employees on an annual basis and is part of new employee orientation.

Example QAPI principles and staff responsibilities related to QAPI and ongoing quality improvement will be included in orientation for all new employees. QAPI will be included in the three day organizational orientation that all new employees are required to attend. All staff will participate in ongoing annual QAPI training which will include quality improvement principles and practices, how to identify areas for improvement, updates on current performance improvement projects, and how they can be involved in performance improvement projects.

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Governance and Leadership – 6

9. Framework for QAPI Determine who the individuals are that will provide the framework or structure for QAPI in your organization. Determine how the QAPI committee will work together to communicate and coordinate QAPI activities.

Example All department managers, the administrator, the director of nursing, infection control and prevention officer, medical director, consulting pharmacist, resident and/or family representative, and three additional staff will provide QAPI leadership by being on the QAPI committee. The three general staff members will be chosen from staff that have direct care and/or service responsibilities, including nursing assistants, nurses, housekeeping aides, maintenance workers, and dietary aides. These staff will serve a one year commitment and the positions will be rotated among staff to ensure as many staff as possible have the opportunity to serve on the committee. The QAPI committee will meet monthly. QAPI activities and outcomes will be on the agenda of every staff meeting and shared with residents and family members through their respective councils and monthly newsletter. The minutes from all meetings will be posted throughout the organization for staff. The QAPI committee will report all activities to the board of directors during their quarterly meeting. The committee will have responsibility for reviewing data, suggestions, and input from residents, staff, family members, and other stakeholders. The QAPI committee will prioritize opportunities for improvement and determine which performance improvement projects will be initiated. The committee will solicit individuals from the organization to conduct performance improvement projects. The committee will monitor progress, provide input, and ensure the individuals involved in the project have the resources they need. The QAPI committee will use a charter for all QAPI projects.

10. Determine how the QAPI activities will be reported to the governing body

Describe how the QAPI activities will be shared and input solicited from the governing bodies.

Example The administrator will facilitate discussion on QAPI activities at the quarterly board of director meetings. QAPI will be a standing agenda item for these meetings. Input will be solicited from board members on QAPI activities. All current projects and outcomes will be reviewed at the board meetings.

11. Describe how a non-punitive culture for staff will be implemented

Describe how leadership will ensure accountability while creating an atmosphere in which staff is comfortable identifying and reporting quality problems.

Example Our organization is a learning environment. We believe in the practices and principles of a non-punitive or Just Culture. All managers will promote staff involvement. Staff will be encouraged to bring concerns, issues, and opportunities for improvement to any

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Governance and Leadership – 7

supervisor/manager. The managers will respond in a consistent approach to encourage staff to bring forward opportunities for improvement. Staff will be encouraged to report errors and near misses to allow the organization to learn from those occurrences and make system changes to prevent recurrences. Staff will be held accountable for their behavioral choices and reckless behavior will not be tolerated. Our goal is to improve the systems that drive our actions.

Resources

• QAPI Rounding Tool: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPILeadershipRoundingTool.pdf

• Examples of Performance Objectives for Job Descriptions and Performance Reviews: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/ExPerformanceObjectivesJobDesc.pdf

• QAPI At a Glance: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIAtaGlance.pdf

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Feedback, Data Systems, and Monitoring – 8

Feedback, Data Systems, and Monitoring 12. Identify Data Sources to Analyze Performance

Identify frequency of data collection and data analysis, targets/benchmarks your organization will use when analyzing data, and establish a plan to communicate data analysis. Choose data sources your organization will use to monitor/analyze your ongoing performance.

Data Sources*

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication

Sugg

estio

ns

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families • QAPI leadership • residents • volunteers

• board meetings • bulletin boards • dashboards • newsletters • posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

Choose a data source

Choose a data source

*Suggested Data Sources • Advanced care planning audits • CMS Quality Measures (long-stay and

short-stay) • Case Mix • CASPER report • Community activities • Consistent assignment • Discharged resident surveys • Drug regimen review summary • Falls • Family Satisfaction

• Fire safety deficiencies • Infection Prevention and Control Program • Information from providers, physicians,

contractors, vendors • Licensed nurse staff hours per resident day • Medication administration audits • Medication errors • Medication room audits • Near Misses (incidents without serious

harm)

• Nursing Assistant staff hours/resident day • Occupancy rates • Rehospitalization rates • Resident satisfaction • Revenue payer sources mix • Staff retention • Staff satisfaction • State survey results • Volunteer hours • Other

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Feedback, Data Systems, and Monitoring | Data Sources to Analyze Performance | EXAMPLE – 9

Example: Data Sources to Analyze Performance

Data Sources

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication Su

gges

tions

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • leadership

team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • Exec. leadership • families • QAPI leadership • residents • staff • volunteers

• board meetings • bulletin boards • dashboard • newsletters • posters • QAPI meetings • staff meetings

• weekly • monthly • quarterly • annually

CMS Quality Measures (long-stay and short-

stay)

monthly state and national data

Leadership team monthly

Executive leadership, QAPI leadership, staff

Meetings, QAPI IDT meetings

Monthly and quarterly

Falls weekly Organizational data Leadership team, QAPI committee

weekly Residents, families,

staff, QAPI leadership

Bulletin boards, dashboard, QAPI

IDT meetings Monthly

Medication errors monthly Organizational data

DON, Leadership team, QAPI Committee

Monthly or asap if

adverse drug event

Board members, QAPI leadership,

staff

Staff meetings, dashboard, QAPI

Meeting

Monthly or sooner if needed

Rehospitalization Rates monthly

Organizational, state and national

data

Leadership team, QAPI committee

monthly

Board members, exec. Leadership, QAPI leadership,

staff

Staff meetings, dashboard, QAPI

meetings Monthly

Resident Satisfaction annually

Identified best practices, state and

national data

Leadership team, QAPI committee

annually

Board members, QAPI leadership, residents, staff,

families

Meetings, bulletin boards, dashboard,

newsletter Annually

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Feedback, Data Systems, and Monitoring | Data Sources to Identify Risk – 10

13. Identify Data Sources to Identify Risk Identify data sources that will help your organization identify and prevent high risk areas, potential problem areas/near misses. Choose data sources that your organization will use to monitor/analyze your organization’s performance.

Data Sources*

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication

Sugg

estio

ns

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families • QAPI leadership • residents • state regulatory

agencies, as required

• volunteers

• board meetings • bulletin boards • dashboards • newsletters • posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

Choose a data source

Choose a data source

*Suggested Data Sources • Abuse, Neglect, Maltreatment reports • Adverse Events - incidents that result in

serious harm, injury, or death • Complaints • Elopement • Family Council minutes • Family Satisfaction Survey findings • Incident reports • Performance Indicators

• Resident Council minutes • Resident Satisfaction Survey findings • Survey findings • Other

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Feedback, Data Systems, and Monitoring | Data Sources to Identify Risk | EXAMPLE – 11

Example: Data Sources to Identify Risk

Data Sources

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication Su

gges

tions

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families • QAPI committee • residents • volunteers

• board meetings • bulletin boards • dashboards • newsletters • posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

Abuse, Neglect, Maltreatment reports

weekly

Identified best practices

Leadership team weekly

Board members, QAPI committee,

state reporting agency,

Reporting requirements,

meetings As needed, weekly

Complaints

weekly

Identified best practices,

organizational date

Leadership team weekly Board members,

QAPI committee meetings As needed, weekly

Family Council minutes monthly Organizational

data

Leadership team, QAPI

committee

monthly QAPI committee, residents families,

board members meetings monthly

Family Satisfaction Survey findings annually Organizational

data, national data

Leadership team, QAPI

committee

annually

Board members, staff, residents, families, QAPI

committee

Meetings, newsletter, annually

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

― Feedback, Data Systems, and Monitoring | Data Sources to Collect Feedback/Input – 12

14. Identify Data Sources to Collect Feedback/Input Identify input from staff, residents, families, and others as appropriate. Choose data sources that your organization will use to monitor/analyze your organization’s performance.

Data Sources*

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication Su

gges

tions

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families • QAPI leadership • residents • volunteers

• board meetings • bulletin boards • dashboards • newsletters • posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

Choose a data source

Choose a data source

*Suggested Data Sources • Family council • Focus groups • Resident council • Satisfaction Surveys • Staff meetings • Suggestion boxes • Other

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

― Feedback, Data Systems, and Monitoring | Data Sources to Collect Feedback/Input | EXAMPLE – 13

Example: Data Sources to Collect Feedback/Input

Data Sources

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication Su

gges

tions

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families

• QAPI committee • residents

• volunteers

• board meetings • bulletin boards

• dashboards • newsletters

• posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

Family council monthly Organizational data

Leadership team, QAPI

committee

monthly QAPI committee, staff, residents,

families

Newsletters, meetings monthly

Resident council monthly Organizational data

Leadership team, QAPI

committee

monthly

Residents, families, staff,

QAPI committee, exec. leadership

Newsletters, meetings monthly

Satisfaction Surveys annually Organizational

date, national data

Leadership team, QAPI

committee

annually

Board members, staff, residents, families, QAPI

committee

Meetings, newsletters, board

meetings annually

Suggestion boxes weekly Organizational

data

QAPI committee, leadership

team

weekly QAPI committee, leadership team Meetings monthly

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Performance Improvement Projects – Page 14

Performance Improvement Projects (PIPs) 15. Describe how your organization will conduct Performance Improvement Projects

Describe the overall plan and reasons why your organization will conduct PIPs to improve care and services.

Example Our organization will conduct Performance Improvement Projects (PIPs) to revise and improve care or services in areas that we identify as needing attention. We will conduct PIPS that will address changes in our systems, cross multiple departments, and have impact on the quality of life and quality of care for residents living in our community. We also will conduct PIPs that will improve care and service delivery, increase efficiencies, lead to improved staff and resident outcomes, and lead to greater staff, resident, and family satisfaction.

16. Describe how potential topics for PIPs will be identified

Describe how the QAPI leadership will identify potential topics for PIPs. Topics should be chosen using a systematic approach that considers all the data the organization is monitoring as well as input from residents, staff, families, stakeholders, etc., including high risk, high volume, and/or problem prone areas that affect the quality of care and quality of life outcomes for residents.

Example The QAPI committee will review data and input on a monthly basis to look for potential topics for PIPs. We will monitor and analyze data, and review feedback and input from residents, staff, families, volunteers, providers, and other stakeholders. We will look at issues, concerns, and areas that need improvement as well as areas that will improve the quality of life and quality of care and services for the residents living and staying in our community. Factors we will consider will include high-risk, high-volume, or problem-prone areas that affect health outcomes and quality of care and areas that affect staff. In addition, we will consider: • Existing standards or guidelines that are available to provide direction for the PIP • Measures that can be used to monitor progress • Quality Measures publically reported on Nursing Home Compare • Goal areas from the Advancing Excellence in America’s Nursing Homes Campaign • Projects that require system or environmental changes, and those affecting staff

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Performance Improvement Projects – Page 15

17. Describe criteria for prioritizing and selecting PIPs

Choosing an area for improvement is an important step for your organization. Potential areas for improvement are based on the needs of the residents and the organization. Factors such as high-risk, high-volume, or problem-prone areas that affect health outcomes, quality of care, and quality of life should be considered. Other factors to consider are the costs to the organization if the area isn’t addressed, how feasible is it to implement a PIP in this area given current resources, and whether the PIP supports organizational goals and priorities. After narrowing topic choices for a PIP, consider which staff will be most affected by the PIP. Are there current resources to support anticipated changes in systems? What training needs will the PIP present? Is there an identified champion(s) to lead the PIP?

Example Our QAPI committee will prioritize topics for PIPS based on the current needs of the residents and our organization. Priority will be given to areas we define as high-risk to residents and staff, high-prevalence, or high-volume areas, and areas that are problem-prone. The QAPI committee will use the CMS Prioritizing Worksheet for Performance Improvement Projects to prioritize PIPs. Consideration will be given to include staff most affected by the PIP. Anticipated training needs will be discussed as well as other resources to complete the PIP.

18. Describe how and when PIP charters will be developed

A project charter is a helpful tool for all PIPS. The charter establishes the goals, scope, timing, milestones, team roles, and responsibilities for the PIP. The charter is usually developed by the QAPI committee and then given to the team that will carry out the PIP. The charter helps the PIP team stay focused by explaining what they are trying to accomplish. It doesn’t tell them how to get there, that is up to the PIP team.

Example A project charter will be developed for each Performance Improvement Project at the beginning of the project that clearly establishes the goals, scope, timing, milestones, team roles, and responsibilities. The PIP charter will be developed by the QAPI committee and then will be given to the team that will carry out the PIP.

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Performance Improvement Projects – Page 16

19. Describe how to designate PIP teams

Describe a process for assembling teams to work on specific PIPs. Consider people in a position to explore the problem. That means staff that are closest to the problem, such as nursing assistants and other direct care staff. Consider including residents and family members, if applicable. Define the required characteristics of any PIP team, this may include that the team be interdisciplinary, representing each of the job role affected by the project, that it include resident representation as appropriate, and that a qualified team leader is selected who has the ability to coordinate, organize, and direct the work.

Example When designating a PIP team, the QAPI committee will consider and give opportunity to all staff in the organization. The QAPI committee will ensure that the team is interdisciplinary, there is representation from each job role that is affected by the project, and resident and/or family member representation is included, if appropriate. When chosen to participate on a PIP team, staff with direct care responsibilities will be replaced whenever possible so that the needs of residents continue to be met. A team leader will be selected that has the ability to coordinate, organize, and direct the work. The team will be accountable to the QAPI committee.

20. Describe how the designated team will conduct the PIP

Describe the expectations of the PIP team and how they will conduct their work. Describe the responsibilities of the team. Items to consider include:

• Determine what information is needed for the PIP • Determine a timeline • Identify and request any needed supplies or equipment • Select or create measurement tools • Prepare and present results • Use a problem solving model such as PDSA (Plan-Do-Study-Act) • Other

Example The PIP teams will consider each PIP a learning process. The team will follow steps and processes that are needed for any quality improvement project. The responsibilities for the PIP teams will be to determine what information is needed for the PIP and how to obtain the information. They will determine a timeline based on the PIP Charter. Requests for needed supplies, staff availability, and equipment will be made to the QAPI committee. The QAPI committee will respond in a timely manner to assure momentum is maintained for the PIP. The team will develop an action plan using the organization’s usual format. Interventions that will make change will be implemented by the team. The team will use root cause analysis to ensure that the root cause and contributing factors are identified. When determining and implementing interventions,

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Performance Improvement Projects – Page 17

PDSA cycles will be used. The team will select and/or create measurement tools to ensure that the changes they are implementing are having the desired effect.

21. Describe your process for documenting and communicating PIPs

Describe how your organization will document the highlights, progress, and lessons learned from your PIP. What project documentation templates will you use to consistently and electronically information about PIPs for review and future reference? Results of PIPs will be communicated via (choose from these):

• Dashboards • QAPI interdisciplinary meetings • Board meetings • Posters • Bulletin boards • Newsletters • Other

The team will report their progress to the QAPI committee on a regular basis. The QAPI committee will ensure that the following groups are informed of PIPs and other QAPI activities (choose from these)

• Board member • Staff • Residents • Families • Volunteers • Community members • Others

Example For ongoing monitoring of the PIP, we will use the CMS PIP Inventory to include milestones, PDSAs, outcomes, and other lessons learned from the PIP. Information about PIPs will be shared via our quality improvement dashboard, quarterly newsletter provided to all residents, families, and staff, and discussed during the QAPI agenda items on all staff, resident, and family monthly meetings.

Resources

• Measure/Indicator Collection and Monitoring Plan: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/MeasIndCollectMtrPlandebedits.pdf

• Measure/Indicator Development Worksheet: https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/measindicatdevwksdebedits.pdf

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Performance Improvement Projects – Page 18

• Prioritization Worksheet for Performance Improvement Projects: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPPriorWkshtdebedits.pdf

• Guide to Creating a Performance Improvement Project Charter: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPCharterWkshtdebedits.pdf

• PIP Launch Checklist: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPLaunchChecklistdebedits.pdf

• PIP Inventory: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PIPInventorydebedits.pdf

• Goal Setting Worksheet: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/QAPIGoalSetting.pdf

• Adverse Drug Event Tracking Tool: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/Adverse-Drug-Event-Trigger-Tool.pdf

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Systematic Analysis and Systemic Action – Page 19

Systematic Analysis and Systemic Action 22. Describe your systematic approach and tools

When making any change, there are many tools which teams can use to identify the cause and contributing factors of issues, including:

• Five Whys • Flowcharting • Fishbone Diagram • Failure Mode and Effects Analysis (FMEA) • Other

Example Our facility uses a systematic approach to determine when in-depth analysis is needed to fully understand identified problems, causes of the problems, and implications of a change. To get at the underlying cause(s) of issue, we bring teams together to identify the root cause and contributing factors using the Five Whys, Flowcharting, and the Fishbone Diagram.

23. Describe your approach to preventing future events and promoting sustained

improvement To implement planned changes, many organizations choose the following courses of action:

• Update policies and procedures that support the change • Clearly define roles and responsibilities for new actions • Communicate the change(s) and its purpose to all those needing to carry out the new actions • Identify and correct barriers/roadblocks that may be in the way of doing things the new way • Integrate the new change(s) into new employee orientation and training • Ensure that there is adequate funding to support the change • Other

Example To prevent future events and promote sustained improvement our organization develops actions to address the identified root cause and/or contributing factors of an issue/event that will affect change at the systems level. We use Plan-Do-Study-Act cycles to test actions and recognize and address “unintended” consequences of planned changes.

24. Describe your approach to ensuring that planned changes/interventions are

implemented and effective Many organizations choose from the following courses of action to ensure that planned changes/interventions are implemented and effective:

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Systematic Analysis and Systemic Action – Page 20

• Choose indicators/measures that tie directly to the new action • Conduct ongoing periodic measurement and review to ensure the new action has been adopted

and is performed consistently • Review some measures more frequently (even daily) by staff to show incremental changes,

which can serve as a reminder for the new action and provide encouragement and reinforcement

• Based on measurement review, make changes in procedure(s) as needed to help facilitate the change

• Other

Example To ensure the planned changes/interventions are implemented and effective in making and sustaining improvements, our organization chooses indicators/measures that tie directly to the new action and conducts ongoing periodic measurement and review to ensure that the new action has been adopted and is performed consistently.

Resources

• Five Whys: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FiveWhys.pdf

• Flowcharting: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FlowchartGuide.pdf

• Fishbone Diagram: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/FishboneRevised.pdf

• Failure Mode and Effects Analysis (FMEA): https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceForFMEA.pdf

• Guidance for Root Cause Analysis: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceforRCA.pdf

• Stratis Health’s Root Cause Analysis Toolkit for Long Term Care: https://www.stratishealth.org/providers/rca-toolkit/

• PDSA Cycles: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/PDSACycledebedits.pdf

• Communication Plan: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/CommunPlan.pdf

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Appendix – Page 21

Appendix: Template, Sections, and Blank Tables

1. Write the Purpose of Your Organization’s QAPI Plan. 2. List of Services You Provide to Residents. 3. Describe How Your QAPI Plan Will Address Key Issues. 4. Current Quality Assurance Activities. 5. Best Available Evidence. 6. Responsibility and Accountability. 7. Describe how QAPI will be adequately sourced. 8. Determine the plan for mandatory QAPI staff training and orientation. 9. Framework for QAPI. 10. Determine how the QAPI activities will be reported to the governing body. 11. Describe how a Non-Punitive Culture for staff will be implemented. 12. Identify Data Sources to Analyze Performance (see blank table on page 22). 13. Identify Data Sources to Identify Risk (see blank table on page 23). 14. Identify Data Sources to Collect Feedback/Input (see blank table on 24). 15. Describe how your organization will conduct Performance Improvement

Projects 16. Describe how potential topics for PIPs will be identified. 17. Describe criteria for prioritizing and selecting PIPs. 18. Describe how and when PIP charters will be developed. 19. Describe how to designate PIP teams. 20. Describe how the designated team will conduct the PIP. 21. Describe your process for documenting PIPs. 22. Describe your systematic approach and tools. 23. Describe your approach to preventing future events and promoting sustained

improvement. 24. Describe your approach to ensuring that planned changes/interventions are

implemented and effective.

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Appendix – Page 22

12. Identify Data Sources to Analyze Performance Identify the frequency of data collection and data analysis, targets/benchmarks your organization will use when analyzing data, and establish a plan to communicate data analysis. Choose data sources that your organization will use to monitor/analyze your organization’s ongoing performance.

Data Sources

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication

Sugg

estio

ns

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families • QAPI leadership • residents • volunteers

• board meetings • bulletin boards • dashboards • newsletters • posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Appendix – Page 23

13. Identify Data Sources to Identify Risk. Identify data sources that will help your organization identify and prevent high risk areas, potential problem areas/near misses. Choose data sources that your organization will use to monitor/analyze your organization’s performance.

Data Sources

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication

Sugg

estio

ns

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families • QAPI leadership • residents • state regulatory

agencies, as required

• volunteers

• board meetings • bulletin boards • dashboards • newsletters • posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

LAKE SUPERIOR QIN QAPI WRITTEN PLAN HOW-TO GUIDE

―Appendix – Page 24

14. Identify Data Sources to Collect Feedback/Input. Identify input from staff, residents, families, and others as appropriate. Choose data sources that your organization will use to monitor/analyze your organization’s performance.

Data Sources

Data collection frequency

Benchmarks used when

analyzing this data source

Who will analyze

the data?

Data analysis

frequency

Data will be communicated

with

Communicate data analysis

via Frequency of

communication

Sugg

estio

ns

• weekly • monthly • quarterly • annually

• applicable clinical guidelines

• identified best practices

• national data • organizational

(chain) data • state data

• HR • Leadership

Team • QAPI

committee

• weekly • monthly • quarterly • annually

• board members • caregivers • community • executive

leadership • families • QAPI leadership • residents • volunteers

• board meetings • bulletin boards • dashboards • newsletters • posters • QAPI

interdisciplinary meetings

• staff meetings

• weekly • monthly • quarterly • annually

The Lake Superior Quality Innovation Network serves Michigan, Minnesota, and Wisconsin, under the

Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

www.lsqin.org | Follow us on social media @LakeSuperiorQIN This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-16-140 080816

About Lake Superior Quality Innovation Network Lake Superior Quality Innovation Network, under contract to Centers for Medicare & Medicaid Services, brings together Medicare beneficiaries, providers, and communities in Michigan, Minnesota, and Wisconsin through data-driven initiatives that increase patient safety, make communities healthier, better coordinate post-hospital care, and improve clinical quality.

For more information about joining National Nursing Home Quality Care Collaborative, visit www.lsqin.org/initiatives/nursing-home-quality/join/ or contact the Lake Superior Quality Innovation Network expert in your state: Michigan: MPRO Kathleen Lavich, 248-465-7399, klavich@mpro.org Minnesota: Stratis Health Kristi Wergin, 952-853-8561, kwergin@stratishealth.org Wisconsin: MetaStar Emily Nelson, 608-441-8242, enelson@metastar.com